We examined the incidence of seven common surgical procedures in seven hospital service areas in southern Norway, in 21 districts in the West Midlands of the United Kingdom, and in the 18 most heavily populated hospital service areas in Vermont, Maine, and Rhode Island. Although surgical rates were higher in the New England states than in the United Kingdom or Norway, there was no greater degree of variability in the rates of surgery among the service areas within the three New England states. Hernia repair was more variable in England (P less than 0.05) and hysterectomy in Norway (P less than 0.05) than in the other countries. There was consistency among countries in the rank order of variability for most procedures: tonsillectomy, hemorrhoidectomy, hysterectomy, and prostatectomy varied more from area to area than did appendectomy, hernia repair, or cholecystectomy. The degree of variation generally appeared to be more characteristic of the procedure than of the country in which it was performed. Thus, differences among countries in the methods of organizing and financing care appear to have little relation to the intrinsic variability in the incidence of common surgical procedures among hospital service areas in these countries. Despite the differences in average rates of use, the degrees of controversy and uncertainty concerning the indications for these procedures seem to be similar among clinicians in all three countries.

A multicentre study of computer aided diagnosis for patients with acute abdominal pain was performed in eight centres with over 250 participating doctors and 16737 patients. Performance in diagnosis and decision making was compared over two periods: a test period (when a small computer system was provided to aid diagnosis) and a baseline period (before the system was installed). The two periods were well matched for type of case and rate of accrual.The system proved reliable and was used in 75-1% of possible cases. User reaction was broadly favourable. During the test period improvements were noted in diagnosis, decision making, and patient outcome. Initial diagnostic accuracy rose from 45-6% to 65 3%. The negative laparotomy rate fell by almost half, as did the perforation rate among patients with appendicitis (from 23.7% to 11-5%). The bad management error rate fell from 0-9% to 0-2%, and the observed mortality fell by 22-0%. The savings made were estimated as amounting to 278 laparotomies and 8516 bed nights during the trial period-equivalent throughout the National Health Service to annual savings in resources worth over £20m and direct cost savings of over £5m.Computer aided diagnosis is a useful system for improving diagnosis and encouraging better clinical practice.

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One hundred and eighteen patients undergoing low colorectal anastomoses were randomly allocated to reconstitution by either single layer interrupted extramucosal sutures or circular staple gun. In the 60 patients undergoing sutured anastomosis there were 2 (3 per cent) clinical leaks and 4 (7 per cent) radiological leaks, and no failures. Of the 58 patients who underwent stapled anastomosis there were 4 failures, 7 (12 per cent) clinical leaks, 14 (24 per cent) radiological leaks and 1 death. Stapled anastomoses were more than ten times as expensive as sutured anastomoses and there were no savings in time or numbers of associated colostomies. An interrupted extramucosal suture technique remains the ultimate standard for low colorectal anastomosis.

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